Slide 1: One Care: Implementation Council Meeting
Executive Office of Health and Human Services
MassHealth Demonstration to 
Integrate Care for Dual Eligibles
November 14, 2023, 10:00 AM – 12:00 PM
Virtual Meeting via Zoom

Note: this footer appears on all slides. 
“Confidential – for policy development only”
Slide 2: Key Outcomes – LTSS Denial Oversight Procedures
MassHealth developed the LTSS Denial Process Review and LTSS Denial Escalations procedures to verify LTSS denials align to the MassHealth One Care care model.

LTSS Denial Process Reviews
•	Verify that health plans’ processes for denying LTSS requests are not in conflict with the One Care care model.
•	Confirm Enrollee’s comprehensive assessment, ICP, and all applicable LTSS guidelines/requirements are reflected in the health plan’s final decision to modify or deny the LTSS request. 
•	Verify LTSS denial decision is consistent with the ICP and current member needs.
•	Verify direct communications take place between Care Coordinators and UM/PA or other LTSS evaluation entities within the health plan.
•	Confirm resolvable administrative denials are resolved and mitigated.
LTSS Denial Escalations
•	Verify all escalated LTSS service requests have been considered by the health plan in full consideration of the Individualized Care Plan (ICP) prior to any denial, partial denial, or reduction.
•	Confirm Enrollees’ ICPs and all applicable LTSS guidelines/requirements are reflected in the health plans’ final decision to modify or deny LTSS requests.
•	Verify LTSS denial decisions are consistent with ICP and current member needs.
•	Confirm administrative denials are mitigated.
Slide 3: Key Outcomes – LTSS Denial Oversight Tools
LTSS Denial Process Reviews
•	LTSS Denial Process Review Summary Workbook 
•	LTSS Denial Process Review Internal Status Tracker
•	LTSS Denial Process Review Master Tracker
•	Process Review Reference Guides
o	MassHealth Reference Guide
o	Health Plan Reference Guide
•	Email Notification Templates:
o	LTSS Denials Request Notification
o	LTSS Denials Selection Notification
o	Additional Information Request
o	Process Review Summary Notification
LTSS Denial Escalations
•	MassHealth LTSS Denial Escalation Reference Guide
•	Health Plan LTSS Denial Escalation Reference Guide
•	Email Notification Templates:
o	Initial Notification of Escalated LTSS Denial
Slide 4: Key Outcomes – LTSS Denial Escalations, Process Reviews
MassHealth launched the LTSS Denial Escalation Process and Process Review to verify denials, review trends across health plans, and align Enrollee documentation and health plan processes to the Care Model.

LTSS Denial Escalation Process (January 2023 – June 2023)
•	Observed reduction in LTSS denial escalations
LTSS Denial Process Review Findings
General Findings (December 2022, April 2023 PCA)1
•	Many ICPs were not person-centered and did not include: 1) supporting information as to why service was requested/denied, 2) alternative care options for denied PCA services, and/or 3) creative use of PCA
•	Many LTSS Denial Summary Form submissions did not include information on whether an Enrollee was offered a Long Term Supports Coordinator (LTS-C), if Enrollee accepted or refused an LTS-C, and/or date of most recent Comprehensive Assessment
•	Many Denial Notices did not include substantive LTSS service reduction/denial reasoning
December 2022 PCA Statistics2
•	15% of LTSS denial cases met all process review criteria 
•	95% of LTSS denial cases met all Comprehensive Assessment criteria
•	20% of LTSS denial cases met all ICP criteria
•	55% of LTSS denial cases met all Health Plan communication criteria
•	65% of LTSS denial cases met all Denial Notice criteria

1 December 2022 and April 2023 PCA LTSS Denial Process Reviews only included PCA Denials for CCA and Tufts.
2 April 2023 PCA LTSS Denial Process Review Statistics are not included
Slide 5: Timeline – April 2023 PCA Denials Process Review

MassHealth implemented the April 2023 PCA LTSS Denial Process Review in May 2023. Key completed and on-going milestones are reflected in the timeline below.

Note: the following information is shown in a timeline on this slide.
May
•	5/18	
o	Round 2 Review Initiated
•	MassHealth requests list of April 2023 PCA LTSS denials from Health Plans
June
•	6/29
o	MassHealth finalizes fillable PDF LTSS Denial Summary Form
July
•	7/7
o	MassHealth communicates randomly selected denials to Health Plans
•	7/21
o	Health plans submit initial documentation

MassHealth conducts Process Review
between 7/21 and 8/7
August
•	8/7
o	Round 2 Review  Concluded
•	MassHealth sends April 2023 PCA LTSS Denial Process Review Summary to Health Plans
•	8/21
o	Health Plans submit Process Review Summary feedback to MassHealth.
TBD
•	Meet with Health Plans individually to review Process Review Summary feedback.

TBD
•	Meet with all Health Plans to review April 2023 PCA LTSS Denial Process Review takeaways.
Slide 6: Next Steps
MassHealth will continue to conduct Process Reviews to verify LTSS denial and Enrollee documentation alignment to Care Model.

•	Address health plan feedback from April 2023 PCA LTSS Denial Process Review
•	Align on updated LTSS Denial Process Review Summary workbook (with section for plan comments)
•	Align on timeline and select period for next round of LTSS Denial Process Review
•	Conduct LTSS Denial Process Review with Commonwealth Care Alliance, Tufts Health Unify, and UnitedHealthcare Connected
•	Reengage LTSS Denial Escalation Process, as applicable.